Transient abrogation of immunosuppression in a patient with chronic mucocutaneous candidiasis following vaccination with Candida albicans

A patient with long-standing chronic mucocutaneous candidiasis had reversed T helper/suppressor (TH/TS) cell ratios, hypergammaglobulinaemia E and serum inhibitors of lymphocyte transformation to mitogens and candida antigens. Following vaccination with whole heat-killed yeasts of Candida albicans, temporary clinical improvement coincided with the return of the TH/TS cell ratio to normal, reduction in concentration of IgE and reduced serum inhibitory activity to Concanavalin A and candida antigens. These changes were not permanent and 6 months after vaccination all indices had reverted to their pretreatment values. The production of antibody to a 47 kDa antigen of C. albicans has been shown to coincide with recovery from systemic disease. High concentrations of this antibody were demonstrated initially in the patient's serum and were unaffected by vaccination. If the 47 kDa antibody is protective, the results of this study suggest that separate immune responses may protect against mucocutaneous and systemic candidiasis and that defective immune responses against mucocutaneous disease need not imply lack of protection against systemic spread.     

Thymic dysfunction in childhood T-acute lymphoblastic leukemia: a possible linkage with a primary thymus involvement.

Experimental models, clinical and histopathological observations suggest a thymic origin of childhood T acute lymphoblastic leukemia (T-ALL). We studied thymic epithelial function in childhood T-ALL as compared to normal controls in order to improve our understanding of the cellular immunodeficiency mechanisms operating in a thymus-linked malignant process. The levels of Facteur Thymique Sérique (FTS) were measured in 9 patients at diagnosis, according to the rosette inhibition assay of Dardenne & Bach (1975). This method is based on the capacity of human serum containing FTS activity to confer on rosette-forming cells (RFC) from adult thymectomized mice a sensitivity to azathioprine identical to that of normal mouse RFC. All patients presented low age-corrected titres of FTS. No zinc deficiency was found, suggesting that low FTS levels are not related to unexpressed FTS biological activity. Plasma from all the children studied contained factors capable of inhibiting the biological activity of FTS in vitro. However, the nature of this inhibitor has not yet been elucidated. Our study shows the presence of a thymic dysfunction in childhood T-ALL, which could partially explain the immunodeficiency described in these patients. The linkage of the leukemic process with a primitive thymic involvement is discussed.     

Chronic mucocutaneous candidiasis. Immunologic studies of three generations of a single family.

A family consisting of eight members in three generations (age 10 months to 53 years) affected with chronic mucocutaneous candidiasis was studied along with three unaffected relatives. Dermatophytosis, loss of teeth and recurrent viral infections were present in some members. Results of tests for endocrinologic, muscle or liver disease, thymoma, iron deficiency, antitissue antibodies and malabsorption were normal in all patients. Antibody function and levels, B cell counts, serum complement, leukocyte enzymes, chemotaxis, phagocytosis and adherence were normal in all members. Plasma inhibitors to lymphocyte transformation and leukocyte inhibitory factor were not found. No unique HLA haplotype or antigen segregated in this family. Evaluation of cell-mediated immunity revealed total cutaneous anergy in three of eight whereas four of the other five had negative lymphocyte transformation and skin tests to Candida but responded normally to other antigens. Leukocyte inhibitory factor was not produced to Candida antigen in all four patients tested. T cell counts were within normal limits in all. Extensive evaluation of all limbs of the immune system in this family revealed a defect in cell-mediated immunity to Candida that appeared to be inherited as a dominant characteristic.     

Successful human umbilical cord blood stem cell transplantation without conditioning in severe combined immune deficiency

A 2-month-old girl with severe combined immunodeficiency (SCID), presented with mild staphylococcal skin infection, lymphopenia, low T cell number, absence of B cells, high number of NK cells, and a negligible response to mitogens. Since her older brother died as a result of SCID 2 years earlier, cord blood was harvested from a sister born 2 1/2 years earlier, who was normal and fully matched both by serology and molecular typing. In view of her clinical condition and in spite of a high number of NK cells with normal activity, HUCBT without preparative conditioning was performed. No G-CSF was administered. Engraftment with mixed chimerism was evident 3 weeks post transplantation. There were no peritransplantation complications. Eighteen months post transplantation, the girl is in excellent condition, blood counts are normal, T cell engraftment is complete, B cell engraftment is proceeding gradually, and the mitogen stimulation tests are normal. Due to the unique nature of HUCB hematopoietic cells, engraftment without conditioning may be possible in patients with SCID with fully matched donors. This is the first HUCBT performed without conditioning.     

Low serum thymic hormone levels in patients with chronic graft-versus- host disease

We tested the hypothesis that chronic graft-versus-host disease (GVHD) is due to inadequate thymic function by examining pretransplant serum levels of facteur thymique serique (FTS). Four of five patients with no detectable FTS activity developed chronic GVHD, while one of four with some FTS activity did. Further patient numbers are needed to confirm or reject this hypothesis. We further postulated that chronic GVHD, whatever its cause, involves thymic epithelium as a target organ. When tested 11 mo or more posttransplant, patients with chronic GVHD had lower absolute FTS levels (p less than 0.02) and lower age-corrected levels (p = 0.05) than patients without chronic GHVD. Low values in chronic GVHD were associated with the disease itself and not its therapy. These findings show that thymic epithelial secretory function is impaired in chronic GVHD, and this may in part be responsible for the immunodeficiency characteristic of these patients.     

Three distinct stages of B-cell defects in common varied immunodeficiency.

B-lymphocyte function of 15 patients with primary common varied immunodeficiency or related disease were examined. All patients had low serum levels of IgM, IgG, and IgA, but 12 of 15 patients had nearly normal numbers of peripheral blood B lymphocytes. Mononuclear cells and B cells from peripheral blood were assayed for B-cell mitogenic responses to anti-Ig mu chain antibodies or to Staphylococcus aureus strain Cowan I (referred to as Cowan I), and for differentiation to Ig-secreting cells of IgM, IgG, and IgA classes in the presence of Cowan I and pokeweed mitogen or T-cell factor. The patients all showed profound B-cell defects in one or more of the assays and could be divided into three approximately equal groups based on their responses. The first group showed normal proliferation in response to the two B-cell mitogens and near normal numbers of IgM-secreting cells but no IgG- or IgA-secreting cells. B cells in the second group showed proliferative responses to Cowan I or anti-mu, but no differentiation to Ig-secreting cells. The third group had no B-cell proliferative responses or differentiation in our assays. In several patients from each group, (i) helper T cells were functional in Ig-secreting-cell responses with purified normal B cells, (ii) patient T cells did not significantly suppress formation of Ig-secreting cells by normal cells in coculture, and (iii) removal of T cells with addition of T-cell-replacing factor, or partial removal of monocytes, did not alleviate any of the defects. These studies show that primary B-cell defects in common varied immunodeficiency occur at several levels, probably representing blocks at different stages of differentiation.     

Serologic tests in the diagnosis of systemic candidiasis. Enhanced diagnostic accuracy with crossed immunoelectrophoreses.

In order to assess the diagnostic value of serologic methods in discriminating between colonization and disseminated infection with Candida species, serum samples from 201 consecutive patients receiving parenteral hyperallmentation were examined for the presence of agglutinating and precipitating antibodies to Candida albicans. In these patients, fungal colonization was detected in 50 per cent, transient fungemia in 6 per cent and disseminated candidlasis in 2.5 per cent. Agglutinating antibodies were of no diagnostic value in separating patients with Candida colonization from those with disseminated infection (sensitivity ? 75 per cent, predictive value ? 20 per cent). Serum Candida precipitins were detected by double immunodiffusion (DID) in all five patients with systemic candidiasis (100 per cent sensitivity); however, since only five of 53 patients with precipitins detected by DID demonstrated evidence of systemic candidiasis, the predictive value of the test was unacceptably low (9 per cent). When the serums which were positive by DID were submitted to crossed immunoelectrophoresis (XIE), precipitin bands to antigens other than mannan were obtained in only nine patients, including all five patients with disseminated candidiasis. Thus, detection by XIE of serum Candida precipitins directed against antigens other than mannan was associated with a predictive value of 56 per cent and a sensitivity of 100 per cent. The detection of serum Candida precipitins by DID is a sensitive screening test in patients at high risk for the development of systemic candidiasis; patients with persistently negative precipitins by DID are unlikely to harbor disseminated candidiasis. If precipitin bands are detected by XIE to antigens other than mannan, there is a high likelihood that the patient has disseminated or invasive Candida infection.     

New perspectives on the immunology of chronic mucocutaneous candidiasis

Chronic mucocutaneous candidiasis is a primary immune deficiency presenting as an inability to clear fungal infections and consequently as persisting and recurring infections of the skin and mucous membranes with yeasts, mostly Candida albicans. Chronic mucocutaneous candidiasis is a heterogeneous clinical syndrome which usually presents in childhood and can have an autosomal recessive, dominant or sporadic mode of inheritance. Most chronic mucocutaneous candidiasis patients also develop accompanying endocrine and inflammatory disorders that suggest an underlying deregulation of the immune system. It has long been recognized that protection from mucocutaneous candidiasis relies on cell-mediated immunity and studies on animal models have highlighted the essential role of type 1 cytokines in protection against Candida spp. Recent data in patients with chronic mucocutaneous candidiasis have documented altered patterns of cytokine production in response to Candida spp. with decreased production of some but not all type 1 cytokines and increased levels of interleukin-10. The defect underlying altered cytokine production remains unknown but studies are in progress addressing the putative role of dendritic cells and pattern recognition receptors in directing cytokine responses. These novel insights into immune mechanisms responsible for protection against Candida spp. are opening new possibilities of immunomodulation and vaccination that could prove beneficial in the management of chronic mucocutaneous candidiasis.     

Hepatic Inflammation, Hepatitis B Replication, and Cellular Immune Function in Homosexual Males with Chronic Hepatitis B and Antibody to Human Immunodeficiency Virus

We measured serum aspartate transaminase (AST) concentration and serum hepatitis B virus (HBV) DNA concentration in homosexual men with chronic HBV infection and a spectrum of immune deficiency as a result of exposure to human immunodeficiency virus (HIV). Serum AST and HBV DNA concentrations were similar in patients with varying immune function as indicated by in vivo criteria (diagnosis and skin tests reactivity) and in vitro criteria (lymphocyte transformation responses to mitogens and Candida and tetanus antigens) and were unrelated to the number of circulating T cells, suppressor/cytotoxic cells, helper cells, natural killer cells, and the helper:suppressor ratio. Serum AST concentration and indices of cellular immune function were similar in patients with varying HBV replicative activity (high and low HBV DNA concentrations). The observed lack of relationship between serum AST concentration and indices of cellular immune function and HBV replication suggests either that other factors determine the severity of hepatic inflammation in chronic HBV infection, or that currently available tests of cellular immune function and HBV replicative activity do not accurately reflect processes in the liver.     

Mucocutaneous candidiasis and thymoma.

The clinical, pathologic and immunologic features of 27 patients with chronic mucocutaneous candidiasis and thymic tumors are reviewed. This form of chronic candidiasis is unique in that the infections do not occur until after the third decade and, in contrast to patients in whom candidiasis develops during infancy or childhood, it is not accompanied by failure of endocrine organs. Instead, the patients have the disorders that often accompany thymoma, such as myasthenia gravis, hypogammaglobulinemia, and abnormalities of the bone marrow and circulating blood elements. Evidence of impaired cell-mediated immunity was found in 16 of the 21 patients in whom studies were made. The pathogenesis of the immunodeficiency in these patients is unknown. Immunosuppressive activities in the plasma of four patients were found, but none of the five patients in whom the appropriate studies were made was found to have suppressor cells. The features of this disorder are unique enough that it should be considered a syndrome, and patients in whom candidiasis develops during their adult years should be studied for the presence of thymoma.     

Selective immunoglobulin M (IgM) deficiency in two immunodeficient adults with recurrent staphylococcal pyoderma.

Two adult men with recurrent pyoderma due to Staphylococcus aureus and a selective deficiency of immunoglobulin M (IgM) antibody synthesis are described. An analysis of each patient's polymorphonuclear leukocyte chemotaxis, phagocytosis and killing of Staph. aureus, serum opsonizaiton of Staph. aureus, and serum and lymphocyte-mediated responses to antigenic stimulation was performed. Family studies revealed a possible autosomal dominant inheritance pattern with heterogenetic expression of various dysgammaglobulinemic states in each patient's first degree relatives. In vivo studies of delayed hypersensitivity and in vitro studies of polymorphonuclear leukocyte and lymphocyte function were normal. A defect in IgM, but not in IgG (immunoglobulin G), antibody synthesis to a number of antigens, and a mild decrease in serum opsonic activity to Staph. aureus correctable by heat inactivated normal human serum were found in each patient. In these patients, the recurrent staphulococcal pyoderma prompted an investigation of host defense mechanisms and revealed low to absent IgM levels and a defect in IgM antibody synthesis.     

Contribution of adherent cells and serum components to immune suppression in Kenyan visceral leishmaniasis

Adherent cells and serum components from Kenyan patients with visceral leishmaniasis were examined with the view to evaluating their contribution to cell-mediated immune suppression. Mitogens (phytohemagglutinin and concanavalin A) and antigens (purified protein derivative, streptokinase-streptodornase, and leishmania) were used as stimulants. Compared to the controls, the contribution of serum components to suppression in presence of any of the mitogens and antigens was not significant. The same applied to adherent cells, except in the presence of leishmania antigen where adherent cells contributed significantly (P less than 0.001). Removal of adherent cells from peripheral blood mononuclear cells of patients and controls considerably increased in vitro lymphocyte responses to both mitogens and antigens (by about twice), suggesting that in this study, the inhibition of in vitro lymphocyte responses to antigens and mitogens by adherent cells was a general phenomenon independent of the presence of the disease.     

A normal level of adenosine deaminase activity in the red cell lysates of carriers and patients with severe combined immunodeficiency disease.

The red cell lysates of two children with severe combined immunodeficiency disease (SCID) exhibited a virtually total absence of adenosine deaminase (adenosine aminohydrolase, EC 3.5.4.4) when standard volumes were assayed. Under these conditions the parents exhibited depressed specific activity except for one mother, whose lysate showed a normal value for activity. Upon storage of the lysate at 4 degrees, a significant amount of activity appeared in one of the SCID children, and the activity of the heterozygous carriers was stimulated. With the use of a sensitive spectrophotometric assay based on conversion of inosine to uric acid, it was shown that the specific enzymatic activity in each of the SCID patients increased progressively as the volume of lysate assayed was lowered. With the smallest amount of lysate this specific activity was in the normal range. Similarly, the specific activity of each of the parents' lysates increased to the level of normal (or, in one case, about twice normal) as smaller volumes were assayed. The activity in the SCID patient was inhibitable by 2-fluoroadenosine and N6-methyladenosine, known competitive inhibitors of human red cell adenosine deaminase. The lysate from the SCID patient was also shown to inhibit adenosine deaminase partially purified from a normal individual. The results are interpreted in terms of a genetically programmed production of an adenosine deaminase inhibitor in at least one variant of the severe combined immunodeficiency disease.     

Decreased suppressor cell activity of alveolar macrophages in bronchial asthma

In 8 allergic asthmatic patients and 12 healthy volunteers, we investigated the effects of alveolar macrophages (AM) on lymphoproliferative responses to polyclonal T-cell mitogens of autologous peripheral blood mononuclear cells (PBMC). The AM were obtained by bronchoalveolar lavage. Peripheral blood mononuclear cells (PBMC) and mitomycin-treated autologous bronchoalveolar cells (BAC) were cocultured at various AM-to-PBMC ratios, and were stimulated or not by phytohemagglutinin and concanavalin A. Half of AM expressed HLA-DR antigens in both the asthmatic and the control group. The BAC from normal subjects were able to modify the lymphoproliferative responses of autologous PBMC to cell mitogens. A dose-dependent effect was observed related to the number of BAC added to PBMC--suppressive at high ratios but enhancing at low ratios. In allergic bronchial asthma, there was a decreased suppressor cell activity of BAC. Among BAC the adherent cells were responsible for this effect. This abnormality could be a part of more general decreased functional activity of AM in allergic bronchial asthma.     

Dietary protein antigenemia in humoral immunodeficiency: Correlation with splenomegaly

Enhanced gastrointestinal absorption of dietary substances is an important feature of normal neonatal life that also exists in particular disease states such as selective IgA deficiency and atopic allergy. In these studies, it is shown that patients with hypogammaglobulinemia have increased absorption of dietary bovine antigens and that most patients have large amounts of these proteins present in the serum even after an overnight fast. The amounts of such proteins were found to be correlated with spleen size and/or peripheral lymphoid hypertrophy. Interestingly, three patients with X-linked agammaglobulinemia did not have detectable amounts of these proteins in the serum nor did they have splenomegaly or lymphadenopathy. It is speculated that hypogammaglobulinemic patients have a specific gastrointestinal mucosal lesion that permits the chronic excessive absorption of dietary antigens and may result in lymphoid hypertrophy.     

Idiopathic late-onset immunoglobulin deficiency with functional T-cell deficiency.

The common features in our two patients were late onset of infections that are known to complicate both T-cell and B-cell deficiencies, decreased numbers of circulating B-cells with low serum immunoglobulin levels, and normal numbers of circulating T-cells, which were, however, defective in the response to delayed hypersensitivity skin test antigens and to mitogens in vitro. The composite of clinical and immunologic aberrations is consistent with the presence of an immune deficiency involving the B-cell system quantitatively and the T-cell system qualitatively.     

Influence of HLA-DR antigens on lymphocyte response to Mycobacterium tuberculosis culture filtrate antigens and mitogens in pulmonary tuberculosis.

SETTING: Influence of HLA-DR antigens and lymphocyte responses in pulmonary TB patients. OBJECTIVE: To elucidate the role of HLA-DR genes/gene products on lymphocyte responses to Mycobacterium tuberculosis antigens and mitogens, the present study was carried out in pulmonary tuberculosis during active and cured stage of the disease. DESIGN: Serological determination of HLA-DR antigens was carried out in 50 active TB patients, 44 cured TB patients and 58 normal healthy control subjects. The influence of HLA-DR antigens on peripheral blood lymphocyte responses to M. tuberculosis culture filtrate antigens and mitogens such as phytohaemagglutinin (PHA) and concanavalin-A (Con-A) was studied in the patients as well as normal healthy control subjects. RESULTS: Of all the DR antigens studied, patients (active TB and cured TB) with DR2 antigen showed an increased lymphocyte response (stimulation index) to a higher dose of antigenic (10 micrograms/ml) stimulation. A significantly lower lymphocyte response to antigen and mitogens was seen in HLA-DR3 positive normal healthy subjects than non-DR3 (DR3 negative) subjects. CONCLUSION: The present study suggests that HLA-DR genes/gene products may be playing an immunoregulatory role in eliciting an immune response against M. tuberculosis antigens and mitogens induced lymphocyte response in pulmonary TB patients and normal healthy subjects.     

Prospective analyses of HIV-1-specific proliferative responses, recall antigen proliferative responses, and clinical outcomes in an HIV-1-seropositive cohort

BACKGROUND: In cross-sectional studies of chronically infected individuals, lymphoproliferative responses to human immunodeficiency virus (HIV) type 1 p24 Gag antigen have previously been associated with lower virus load. It was not known whether this association would be predictive of better clinical outcome in longitudinal studies. METHODS: In blood samples from 608 HIV-seropositive individuals enrolled in a trial of glycoprotein 160 vaccine therapy over the course of 3-5 years, lymphoproliferative responses to HIV-1 antigens, tetanus toxoid (TT), and mitogens were measured and correlated with clinical outcome and other parameters of progression. Baseline lymphoproliferative responses to antigens and mitogens were used to categorize the cohort into responders or nonresponders. RESULTS: Although response to recall antigens did not correlate with clinical indices of disease progression, positive baseline lymphoproliferative responses to p24 and TT were associated with lower plasma levels of HIV-1 RNA. Persistently positive lymphoproliferative responses to the antigens also inversely correlated with repeated measurements of virus load, although the significance was lost once the measurements were adjusted for virus load and CD4(+) cell count at baseline, by use of generalized estimating equation analysis. CONCLUSIONS: These observations suggest that the effect of the association between lymphoproliferative response and virus load is established early during HIV-1 infection and does not increase over time and suggest that antigen-specific lymphoproliferative responses reflect the dynamic state of HIV-1 infection and are inversely associated with virus load.     

Cellular immune competence in bancroftian filariasis

Lymphocyte proliferative responses to homologous and heterologous filarial antigens, mitogens and purified protein derivatives (PPD) were analysed in a group of 37 subjects from an area endemic for bancroftian filarial infection. The majority of the subjects without any clinical or parasitological evidence of filariasis (endemic normals) reacted with homologous microfilarial antigens only. Non-treated patients with patent microfilaraemia, did not respond to homologous of heterologous microfilarial antigens. In contrast, diethylcarbamazine (DEC)-treated microfilaraemic patients, reacted with homologous filarial antigens. Patients with elephantiasis reacted to microfilarial and adult worm antigens. Response to PPD was marginally depressed in patent microfilaraemic patients and a rise was observed in elephantiasis cases. Endemic normals exhibited normal response to PPD. Responses to mitogens were depressed throughout the course of the infection.     

Allogeneic bone marrow transplantation in man: in vitro activity of FTS-Zn on T-cell markers and functions

Thymulin (FTS-Zn) is a synthetic metallo-nonapeptide similar to the serum factor of thymic origin FTS, which induces the maturation of lymphoid cells. The activity of this compound on peripheral blood mononuclear cells from 12 bone marrow recipients was studied in vitro. It was demonstrated that thymulin was able to induce or modulate the expression of T-cell membrane markers, to enhance the proliferative responsiveness of lymphocytes to mitogens or allogeneic cells, and to increase mononuclear cells' natural killer activity. This in vitro responsiveness was contemporary to a transient decrease of FTS levels in the patients' serum, documented by sequential assays. These results suggest that thymulin could be of interest as a prophylactic therapy to speed up the immunological reconstitution of bone marrow recipients.